Continuing problems?

For the past 19 years, Gerard Madden has built a thriving 3,000-patient practice in the north-east coastal town of Stonehaven. As committed to his patients as the next dentist he lives and breathes a belief in total patient care.

But news that the government is imposing its will and forcing continuous registration onto a highly reluctant profession – despite the evidence pointing to the contrary – has left him more than a little angry at the prospect.

There is no doubt in his mind that the new rules will lead to what he described as a “logistical nightmare” with potentially very serious implications for the country’s long-term oral health.

“The whole purpose of continuing care and registering is to try and encourage patients to go to a dentist regularly so their teeth never get into a state where they might have real problems,” he said.

“We have been trying to re-educate people to come to the dentist regularly and that will be undone.”

Dr Madden argues that after the initial three years, dentists fees will drop but patients will still be entitled to the same service, such as emergency treatment within 24 hours.

“We will have to leave many more slots open in case people ring up and will end up with huge lists of patients for whom we will not be able to provide the standard of care the NHS wants.

“I would hate to think that a patient who I saw once 15 years ago would be able to call me up at 8.30 one morning and say ‘I need to see you now.’

“I feel it is discouraging patients from attending regularly and keeping their oral health up to standard.”

For a year, the BDA’s Scottish Dental Practice Committee worked long and often arduous hours, painstakingly building and presenting the case against continuous registration to the Scottish government and its negotiators.

In October last year, the BDA announced the results of a consultation sent to every NHS-listed dentist in Scotland, which revealed that 90 per cent of respondents were against continuous registration.

However, despite the committee’s best efforts, the government haschosen to impose the new regulations with effect from 1 April.

Dr Robert Kinloch, the new chairman of the BDA’s Scottish Dental Practice Committee (SDPC) is, along with his colleagues, bitterly disappointed in her decision. He believes it is politically motivated by a government simply seeking to increase registration figures.

When asked by Scottish Dental why he felt the Scottish Government didn’t listen to the BDA’s arguments, Dr Kinloch said: “They have ignored the profession’s advice, for what reason I can only speculate.

“We would say there is a political agenda here in that obviously the Scottish Government want to show registration numbers going up. But that doesn’t show the actual percentage of the population that is visiting their dentist.

“The registration number is only a very rough guide to allow them to say that there is some form of relationship. The figure that we really need to see is the percentage of the population who are seeing their dentist on an annual basis.”

Dr Kinloch continued by saying he also believes that the decision could put an unwanted strain on GDPs: “If this particular process goes on over a period of time you will get to a stage where you will have a dental list that is potentially beyond the capabilities of the dentist to service. You will have a list that you will be responsible for and there is only a finite number that you can deal with.”

He also argued that this could potentially lead to an increase in patients needing emergency treatment, which would not only disrupt a dentist’s appointment book but would mean that dentists would be as responsible for irregular attendees as for their regular patients, and yet they would not be paid in relation to that.

He said: “When registration was increased to four years they effectively gave us the full payments for the four years. But now they are reducing it back so that anybody you haven’t seen for three years will have their payments reduced down to 20 per cent. And we still have to meet 100 per cent of the obligations to treat these patients.

“If a patient you haven’t seen for over three years comes back to see you, for emergency treatment say, then this will re-trigger the relationship at full payment for three years. But again, you still have to have the responsibility for these particular patients. We will be expected to have full responsibility for only 20 per cent of the fee.”

In implementing the changes the government has put forward the argument that lifelong dental registration would lead to a more stable relationship between dentists and patients and that their oral health could be more easily monitored. However, Dr Kinloch and the BDA have refuted this suggestion by saying that it could lead to an increase in the rates of oral cancer if patients aren’t being screened as regularly as they would be under a normal recall relationship.

He said: “The Public Health Minister Shona Robison has mentioned that the better known a patient’s history, the more likely the patient is to be treated appropriately. Well, if you don’t see somebody for five years I don’t really know how you can do that.

“It could potentially have a dramatic impact on oral health. If you are not having your teeth checked for decay and also your gums and bone levels checked, a lot can change within a period of a year or so. If you are not seeing somebody for potentially five years, how can you really assess them?”

As with every relationship, however, Dr Kinloch argued that there is always the need for patients to take a certain amount of responsibility themselves. And this is where he believes the government needs to act in order to encourage the public to register and visit their dentist more often. He said: “Having signalled their intention to press ahead with this change, the government must now work very hard to promote regular attendance to patients and ensure that the efforts of the profession in encouraging patients to visit them regularly are not undone.”

Despite the obvious difference of opinion between the BDA and the Scottish Government, Dr Kinloch maintains that they are still keen to work with ministers on this and other matters in the future: “I think there are always areas of policy where an organisation such as the BDA, which is coming from a background of representing its members, and the wishes of government, will not coincide. For example, we would always feel that more money should be spent on dentistry. We did give figures to the government previously as to what we thought the action

plan should spend on dentistry and the government figure has never got to the same level that we feel it should be funded at.

“However, we have to continue to engage the government and show them where problems are occurring on these matters and I would certainly still very much want to have an ongoing relationship with the Scottish Government and with the Chief Dental Officer.”

Even after striking this conciliatory tone, Dr Kinloch and his colleagues at the BDA maintain an air of disappointment at the decision to move to lifelong registration.

“I think by doing this the government are effectively letting down patients,” he said.

Interviewed by Scottish Dental, Shona Robison was forthright in her defence of the decision to introduce the new policy. She said she was “a little disappointed” at the BDA’s stance, adding that after lengthy discussions she believed there to have been a “clear understanding” established of the way forward.

“The reason for continuous registration goes back to the Dental Action Plan from five years
ago that we inherited and where continuous registration was set out. I agree with that because I believe it is about developing a lifelong relationship between the patient and the dentist that is consistent with what happens elsewhere in primary care. It would seem strange, would it not, if GPs were to de-register every three years and I have been of the view that in order to develop a stable relationship between the patient and the dentist over a long time then continuous registration is one way of achieving that.

“Clearly it is important that the patient takes responsibility as well and we’ve agreed that there needs to be some patient education around the need for regular attendance, and we will be doing that through patient communication to make sure they understand their responsibility to attend on a regular basis,” she said.

Defending the charge that she was acting in a politically motivated manner, the minister dismissed the notion as nonsense.

“Well, it’s not politically motivated because it’s been around for five years, we’re not doing something that has suddenly cropped up, or a wheeze that I’ve thought of. It’s not like that.”

The relationship between the BDA and government may still be intact, but if continuous registration pans out the way the profession fears, what state will the relationship between dentists and patients be reduced to? And, worst still, what state might the nation’s oral health be left in as a result?

Introduction of non-time limited registration

1. This memorandum advises dentists of changes to the continuing care and capitation period which take effect from 1 April 2010.

The Memorandum to NHS:PCA(D)(2009)2, issued on 20 March 2009, advised of a two step change to continuing care and capitation arrangements with the intention to make registration with a dentist non-time limited from 1 April 2010.

To provide for this change in the registration period the NHS (General Dental Services) (Scotland) Regulations 1996 are being amended with effect from 1 April 2010 to remove all references to lapsing of a registration period.

This means that from 1 April 2010 all existing patients registered with a dentist under a continuing care and capitation arrangement and all new patients registered with a dentist under a continuing care and capitation arrangement will be registered for life (although dentists will continue to be able, if they choose, to take the necessary steps to de-register any patients that they no longer wish to treat under NHS arrangements).

Registration arrangements will no longer lapse after a set period. A registration arrangement will, however, come to an end, and continuing care or capitation payments cease, where Practitioner Services have determined that a patient has died, moved out of the country or registered with another dentist in Scotland.

Reduction in Continuing Care and Capitation Payments

Continuing care and capitation payments will be paid on a monthly basis for all patients registered with a dentist.

However, where a patient has not attended the dentist for three years or more, and the dentist has not therefore submitted a payment claim form (GP17) to Practitioner Services in respect of that patient, then the continuing care or capitation payment (items 41(a) and 45(a) and (b) of Determination I to the Statement of Dental Remuneration) will reduce to 20 per cent of the relevant fee. Any payment due under item 41(b), (c) and (e) and 45(c) and (d) of Determination I will also be reduced to 20 per cent of the relevant fee for any patient where a GP17 has not been submitted for three years or more. Payments will return to the full amount when a GP17 is subsequently submitted by the dentist, or another dentist acting on his/her behalf, for any patient in respect of whom payments have reduced to 20 per cent.}

Biography: Robert Kinloch

Dr Robert Kinloch (56) succeeded Colin Crawford as chairman of the Scottish Dental Practice Committee (SDPC) in February after Colin left to take up a post in the salaried service.
After graduating from Glasgow Dental School in 1977 Dr Kinloch set about dedicating his career to general dental practice, working initially as an associate and then setting up his own NHS practice in Alexandria in 1981, where he remains to this day.

He is a member of the BDA’s executive council, chairman of the BDA’s Scottish council and also chairman of the BDA’s UK and Scottish policy health groups. Dr Kinloch is also a former president of the West of Scotland Branch from 2008 to 2009.

Dr Kinloch is married to his wife of 32 years Elizabeth and has two grown-up children, Colin (26) and Emma (22).

VIEWPOINT: Chris Parkin

Chris Parkin from the Stoneyfield Dental Practice in Inverness, the largest committed NHS practice in the North of Scotland, said: “We welcome the changes. For any practice that is seeking to expand its NHS patient base it will be a help, but for practices wishing to reduce their NHS caseload by natural wastage; it is a disaster.

“I don’t think it will in any way deter people from coming to the dentist and will have no detrimental impact of people’s oral health. We regularly have people who phone us up as their last point of contact, no matter how long ago it was, and they expect you to greet them like long lost buddies. We will now be paid to greet them as long lost buddies.”

VIEWPOINT: David MacPherson

David MacPherson, principal dentist at Whitemoss Dental Practice in East Kilbride, said: “The vast majority of patients won’t be affected. However, some people will simply think: ‘I’ll wait until I have a problem’, by which time that problem may be too big to fix.

“The service will become more emergency driven and patients who are currently attending regularly are in danger of being ‘bumped’ by people who haven’t, but who have an emergency.

“It’s absolutely ludicrous.”

VIEWPOINT: Lachie MacDonald

Lachie MacDonald, of Johnstone Street Dental Care in Paisley, said: “I see continuing registration for dental patients as a last desperate measure of the government to manipulate the figures as more dentists leave the NHS. I think this will accelerate the process.

“Is this what the politicians actually have in mind? To be able to say: ‘It’s not our fault that dentistry is gradually being removed from the NHS. It’s the fault of the greedy, grasping, unfeeling selfishness of these dentists!’

“I will continue to work for the NHS.

“Somebody must!”

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